Gastroesophageal reflux disease, or GERD, occurs when
the lower esophageal sphincter (LES) does not close properly and stomach
contents leak back, or reflux, into the esophagus. The LES is a ring of
muscle at the bottom of the esophagus that acts like a valve between the
esophagus and stomach. The esophagus carries food from the mouth to the
stomach.

When refluxed stomach acid touches the lining of the
esophagus, it causes a burning sensation in the chest or throat called
heartburn. The fluid may even be tasted in the back of the mouth, and
this is called acid indigestion. Occasional heartburn is common but does
not necessarily mean one has GERD. Heartburn that occurs more than twice
a week may be considered GERD, and it can eventually lead to more serious
health problems.

Anyone, including infants, children, and pregnant women,
can have GERD.

What are the symptoms of GERD?

The main symptoms are persistent heartburn and acid
regurgitation. Some people have GERD without heartburn. Instead, they
experience pain in the chest, hoarseness in the morning, or trouble swallowing.
You may feel like you have food stuck in your throat or like you are choking
or your throat is tight. GERD can also cause a dry cough and bad breath.

GERD in Children

Studies* show that GERD is common and may be overlooked
in infants and children. It can cause repeated vomiting, coughing, and
other respiratory problems. Children's immature digestive systems are
usually to blame, and most infants grow out of GERD by the time they are
1 year old. Still, you should talk to your child's doctor if the problem
occurs regularly and causes discomfort. Your doctor may recommend simple
strategies for avoiding reflux, like burping the infant several times
during feeding or keeping the infant in an upright position for 30 minutes
after feeding. If your child is older, the doctor may recommend avoiding

sodas that contain caffeine

chocolate and peppermint

spicy foods like pizza

acidic foods like oranges and tomatoes

fried and fatty foods

Avoiding food 2 to 3 hours before bed may also help.
The doctor may recommend that the child sleep with head raised. If these
changes do not work, the doctor may prescribe medicine for your child.
In rare cases, a child may need surgery.

*Jung AD. Gastroesophageal reflux in infants and children.
American Family Physician. 2001;64(11):1853-1860.

What causes GERD?

No one knows why people get GERD. A hiatal hernia may
contribute. A hiatal hernia occurs when the upper part of the stomach
is above the diaphragm, the muscle wall that separates the stomach from
the chest. The diaphragm helps the LES keep acid from coming up into the
esophagus. When a hiatal hernia is present, it is easier for the acid
to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia
can happen in people of any age; many otherwise healthy people over 50
have a small one.

How is GERD treated?

If you have had heartburn or any of the other symptoms
for a while, you should see your doctor. You may want to visit an internist,
a doctor who specializes in internal medicine, or a gastroenterologist,
a doctor who treats diseases of the stomach and intestines. Depending
on how severe your GERD is, treatment may involve one or more of the following
lifestyle changes and medications or surgery.

Lifestyle Changes

If you smoke, stop.

Do not drink alcohol.

Lose weight if needed.

Eat small meals.

Wear loose-fitting clothes.

Avoid lying down for 3 hours after a meal.

Raise the head of your bed 6 to 8 inches by putting
blocks of wood under the bedposts--just using extra pillows will not
help.

Medications

Your doctor may recommend over-the-counter antacids,
which you can buy without a prescription, or medications that stop acid
production or help the muscles that empty your stomach.

Antacids, such as Alka-Seltzer, Maalox, Mylanta,
Pepto-Bismol, Rolaids, and Riopan, are usually the first drugs recommended
to relieve heartburn and other mild GERD symptoms. Many brands on the
market use different combinations of three basic salts--magnesium, calcium,
and aluminum--with hydroxide or bicarbonate ions to neutralize the acid
in your stomach. Antacids, however, have side effects. Magnesium salt
can lead to diarrhea, and aluminum salts can cause constipation. Aluminum
and magnesium salts are often combined in a single product to balance
these effects.

Calcium carbonate antacids, such as Tums, Titralac,
and Alka-2, can also be a supplemental source of calcium. They can cause
constipation as well.

Foaming agents, such as Gaviscon, work by covering
your stomach contents with foam to prevent reflux. These drugs may help
those who have no damage to the esophagus.

H2 blockers, such as
cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR),
and ranitidine (Zantac 75), impede acid production. They are available
in prescription strength and over the counter. These drugs provide short-term
relief, but over-the-counter H2 blockers should
not be used for more than a few weeks at a time. They are effective for
about half of those who have GERD symptoms. Many people benefit from taking
H2 blockers at bedtime in combination with a
proton pump inhibitor.

Proton pump inhibitors include omeprazole (Prilosec),
lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex),
and esomeprazole (Nexium), which are all available by prescription. Proton
pump inhibitors are more effective than H2 blockers
and can relieve symptoms in almost everyone who has GERD.

Another group of drugs, prokinetics, helps strengthen
the sphincter and makes the stomach empty faster. This group includes
bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also
improves muscle action in the digestive tract, but these drugs have frequent
side effects that limit their usefulness.

Because drugs work in different ways, combinations of
drugs may help control symptoms. People who get heartburn after eating
may take both antacids and H2 blockers. The antacids
work first to neutralize the acid in the stomach, while the H2
blockers act on acid production. By the time the antacid stops working,
the H2 blocker will have stopped acid production.
Your doctor is the best source of information on how to use medications
for GERD.

What if symptoms persist?

If your heartburn does not improve with lifestyle changes
or drugs, you may need additional tests.

A barium swallow radiograph uses x rays to
help spot abnormalities such as a hiatal hernia and severe inflammation
of the esophagus. With this test, you drink a solution and then x rays
are taken. Mild irritation will not appear on this test, although narrowing
of the esophagus--called stricture--ulcers, hiatal hernia, and other
problems will.

Upper endoscopy is more accurate than a barium
swallow radiograph and may be performed in a hospital or a doctor's
office. The doctor will spray your throat to numb it and slide down
a thin, flexible plastic tube called an endoscope. A tiny camera in
the endoscope allows the doctor to see the surface of the esophagus
and to search for abnormalities. If you have had moderate to severe
symptoms and this procedure reveals injury to the esophagus, usually
no other tests are needed to confirm GERD.

The doctor may use tiny tweezers (forceps) in the endoscope to remove
a small piece of tissue for biopsy. A biopsy viewed under a microscope
can reveal damage caused by acid reflux and rule out other problems
if no infecting organisms or abnormal growths are found.

In an ambulatory pH monitoring examination,
the doctor puts a tiny tube into the esophagus that will stay there
for 24 hours. While you go about your normal activities, it measures
when and how much acid comes up into your esophagus. This test is useful
in people with GERD symptoms but no esophageal damage. The procedure
is also helpful in detecting whether respiratory symptoms, including
wheezing and coughing, are triggered by reflux.

Surgery

Surgery is an option when medicine and lifestyle changes
do not work. Surgery may also be a reasonable alternative to a lifetime
of drugs and discomfort.

Fundoplication, usually a specific variation
called Nissen fundoplication, is the standard surgical treatment for GERD.
The upper part of the stomach is wrapped around the LES to strengthen
the sphincter and prevent acid reflux and to repair a hiatal hernia.

This fundoplication procedure may be done using a laparoscope
and requires only tiny incisions in the abdomen. To perform the fundoplication,
surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication
has been used safely and effectively in people of all ages, even babies.
When performed by experienced surgeons, the procedure is reported to be
as good as standard fundoplication. Furthermore, people can leave the
hospital in 1 to 3 days and return to work in 2 to 3 weeks.

In 2000, the U.S. Food and Drug Administration (FDA)
approved two endoscopic devices to treat chronic heartburn. The Bard EndoCinch
system puts stitches in the LES to create little pleats that help strengthen
the muscle. The Stretta system uses electrodes to create tiny cuts on
the LES. When the cuts heal, the scar tissue helps toughen the muscle.
The long-term effects of these two procedures are unknown.

Implant

Recently the FDA approved an implant that may help
people with GERD who wish to avoid surgery. Enteryx is a solution that
becomes spongy and reinforces the LES to keep stomach acid from flowing
into the esophagus. It is injected during endoscopy. The implant is approved
for people who have GERD and who require and respond to proton pump inhibitors.
The long-term effects of the implant are unknown.

What are the long-term complications of GERD?

Sometimes GERD can cause serious complications. Inflammation
of the esophagus from stomach acid causes bleeding or ulcers. In addition,
scars from tissue damage can narrow the esophagus and make swallowing
difficult. Some people develop Barrett's esophagus, where cells in the
esophageal lining take on an abnormal shape and color, which over time
can lead to cancer.

Also, studies have shown that asthma, chronic cough,
and pulmonary fibrosis may be aggravated or even caused by GERD.

For information about Barrett's esophagus, please see
the Barrett's Esophagus
fact sheet from the National Institute of Diabetes and Digestive and Kidney
Diseases.

Points to Remember

Heartburn, also called acid indigestion, is the most
common symptom of GERD. Anyone experiencing heartburn twice a week or
more may have GERD.

You can have GERD without having heartburn. Your
symptoms could be excessive clearing of the throat, problems swallowing,
the feeling that food is stuck in your throat, burning in the mouth,
or pain in the chest.

In infants and children, GERD may cause repeated
vomiting, coughing, and other respiratory problems. Most babies grow
out of GERD by their first birthday.

If you have been using antacids for more than 2 weeks,
it is time to see a doctor. Most doctors can treat GERD. Or you may
want to visit an internist--a doctor who specializes in internal medicine--or
a gastroenterologist--a doctor who treats diseases of the stomach and
intestines.

Doctors usually recommend lifestyle and dietary changes
to relieve heartburn. Many people with GERD also need medication. Surgery
may be an option.

Hope Through Research

No one knows why some people who have heartburn develop
GERD. Several factors may be involved, and research is under way on many
levels. Risk factors--what makes some people get GERD but not others--are
being explored, as is GERD's role in other conditions such as asthma and
bronchitis.

The role of hiatal hernia in GERD continues to be debated
and explored. It is a complex topic because some people have a hiatal
hernia without having reflux, while others have reflux without having
a hernia.

Much research is needed into the role of the bacterium
Helicobacter pylori. Our ability to eliminate H. pylori
has been responsible for reduced rates of peptic ulcer disease and some
gastric cancers. At the same time, GERD, Barrett's esophagus, and cancers
of the esophagus have increased. Researchers wonder whether having H.
pylori helps prevent GERD and other diseases. Future treatment will
be greatly affected by the results of this research.

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in this document are used only because they are considered necessary in
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this does not mean or imply that the product is unsatisfactory.

National Digestive Diseases Information Clearinghouse

The National Digestive Diseases Information Clearinghouse
(NDDIC) is a service of the National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes
of Health under the U.S. Department of Health and Human Services. Established
in 1980, the clearinghouse provides information about digestive diseases
to people with digestive disorders and to their families, health care
professionals, and the public. NDDIC answers inquiries, develops and distributes
publications, and works closely with professional and patient organizations
and Government agencies to coordinate resources about digestive diseases.

Publications produced by the clearinghouse are carefully
reviewed by both NIDDK scientists and outside experts. This fact sheet
was reviewed by G. Richard Locke, M.D., Mayo Clinic; and Joel Richter,
M.D., Cleveland Clinic Foundation.